High-risk patients and medicines

The ‘NHS Discharge Medicines Service – Essential Service: Toolkit for pharmacy staff in community, primary and secondary care’ includes suggested referral criteria for hospital and acute care pharmacy teams to consider when deciding which patients may benefit from referral through the DMS.

Patients deemed high-risk include:

• People taking more than five medicines, where the risk of harmful effects and drug interactions is increased
• Those who have had new medicines prescribed while in hospital
• Those who have had medicine change(s) while in hospital
• Those who have experienced myocardial infarction (heart attack) or a stroke, due to the likelihood of new medicines being prescribed
• Those who appear confused or muddled about their medicines on admission/when getting ready for discharge and have already needed additional support from a healthcare professional
• Those who have help at home to take their medicines
• Those who have a learning disability.

Multiple resources, including those from NHS Improvement, cite a list of medicines deemed high-risk. These include, but are not limited to: 

• Anticoagulants (e.g. warfarin, dabigatran), antiepileptics, digoxin, opioids, methotrexate, antipsychotics, cardiovascular medicines (e.g. beta-blockers, diuretics), controlled drugs, valproate, amiodarone, lithium, insulin, non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin, among others
• Newly started respiratory medicines, including inhalers
• Medicines requiring follow-up – for example, blood monitoring, dose increase or dose reduction
• Medicines that have a potential to cause dependence, such as opioids
• Medicines in varying or changing doses, either increasing or decreasing over a period of time.

NHS Trusts, supported by their local AHSN, will work with LPCs, PCNs and CCGs to agree criteria for referring patients to community pharmacy through the DMS (where Trusts do not already have a TCAM service in place). Criteria should also consider local population needs and the NHS Trust’s capability to refer patients.

When discussing consent to transfer information about their medicines, the patient should be a partner in the shared decision-making process. Hospital/acute care teams will need to be able to describe what the service will mean for the patient, including the support they can expect from the community pharmacist and pharmacy technician. The hospital/acute care team will also need to know how the service could benefit the patient and be able to answer any questions the patient may have or know how to find out the answer. The NHS Trust will have a standard operating procedure (SOP) covering how the referral process works for its organisation.

Practice points

• Reflect on your communication with other pharmacy teams or other healthcare professionals in making transfer of care as safe as possible
• Think about how you could improve the systems where you work.